Surgical management of iatrogenic vascular injuries

Iatrogenic vascular injury is an abnormal state that occurs in patients as a result of inadvertent or erroneous treatment by physicians or surgeons. We describe our 10 year experience with patients who underwent surgical repair of iatrogenic vascular injuries after catheterization or operation. Thirty one patients with iatrogenic vascular injury incurred between February 2001 and February 2011 who were surgically managed in our Department were reviewed retrospectively. The clinical presentation, localization and type of vascular injury were each analyzed. This study group consisted of 19 males and 12 females, ranging in age from 16 to 69 years with an average age of 47.8 years. Of the 31 iatrogenic vascular injuries, 19 resulted from a percutaneous procedure and 12 were sustained intraoperatively. The intraoperative iatrogenic injuries affected the inferior vena cava in three patients, left renal vein in one, external iliac artery in four, common carotid artery in three, and internal carotid artery in one. Eleven patients associated with catheterization were operated on immediately. The remaining eight were operated on an elective surgical basis [Pseudoaneurysm or arteriovenous fistula]. All patients made an uneventful recovery. Although experience and thorough knowledge of the vascular anatomy can prevent many potential iatrogenic vascular injuries, the risk of iatrogenic vascular injury cannot be completely eliminated. Therefore, we recommend that major operations requiring dissection in proximity to the vascular structures, and catheter based diagnostic or therapeutic procedures should be performed only in hospitals with an established vascular surgery department

Emergent surgical retrieval of an embolized septal occluder from the main pulmonary artery

Surgical closure of ASD has been used for over 50 years and appears to be a safe and effective operation. However, over the past decade, transcatheter closure techniques have been increasingly practiced. We present a case of 51 -year old woman with atrial septal defect [ASD]. She presented with progressive decrease in exercise tolerance. Echocardiographic examination-showed the ASD and a 26mm septal occluder device [Cardio-fix septal occluder] was successfully deployed under fluoroscopic and echocardiographic guidance. However, the patient suddenly complained of palpitation and sustained ventricular tachycardia thirty minutes after the procedure. A repeat echocardiographic examination confirmed embolization of the device into main pulmonary artery. Due to failure of capture of the device via multisnare, the patient was immediately taken to the operating room for removal of the device and surgical closure of the defect. The embolized device was grasped and retrieved from proximal pulmonary artery between index and middle fingers inserted into the main pulmonary artery via the tricuspid and pulmonary valves. The ASD was closed by running nonabsorbable polypropylene suture. Postoperative recovery was uneventful. The patient was discharged home after a total of six days of hospitalization

Surgical management of atrial septal defect in patients over 40 years of age

Atrial septal defect [ASD] makes up about 10% of all congenital heart diseases diagnosed after delivery and up to 30-40% of heart defects diagnosed in patients aged over 40 years. The objective of this study was to evaluate the effects of surgical ASD repair on functional status, right ventricular size, cardiothoracic ratio and pulmonary hypertension in patients over 40 years of age. Between the period of August 2001 and August 2010, 20 of the patients who had undergone surgical repair of a secundum ASD when they were aged >40 years at our institution were included in this study. To evaluate the effects of surgery on clinical outcome, we compared functional status, echocardiographic and radiographic findings of the patients before and after surgery. The defect was closed with either a running nonabsorbable suture or an autologous pericardial patch. Postoperatively, clinical status of the patients improved significantly. The mean NYHA functional class decreased from 2.8 +/- 0.4 to 1.5 +/- 1.1 [P < 0.001]. Postoperatively, mean right ventricle diameter was found regressed from 38.2 +/- 9.3 mm to 34.8 +/- 6.2 mm [P < 0.002] at a median interval of four months. The pulmonary artery pressures were also significantly decreased [p < 0.002]. The data provided by this study suggest that surgical repair of ASD improves functional status and relieves symptoms. Therefore, we suggest that ASDs that are unsuitable for transcatheter closure or requiring additional surgical intervention should undergo surgical repair to reduce subsequent morbidity and mortality, in patients including over 40 years of age

Surgical repair of delayed chronic type A dissection after previous coronary artery bypass grafting

We report of a 57 years-old woman who had undergone coronary artery bypass three years previously. Computed tomography [CT] revealed that the ascending aorta was dilated to about 7cm in diameter, with type A dissection. Angiography revealed that left internal thoracic artery [LITA] graft to left anterior descending artery [LAD] and saphenous vein grafts to posterior descending artery [PDA] branch of the right coronary artery [RCA] and second obtuse marginal [OM] branch of the circumflex artery [CX] correspondingly were patent. Though the risk of surgical, treatment via repeat median sternotomy is usually very high in these cases, we successfully performed the reoperation using profound hypothermic circulatory arrest. We dissected the mediastinum by using a sternum retractor for ITA and saphenous vein grafts dissection. We didn't use cardioplegia during profound hypothermic circulation

Management of giant venous aneurysms secondary to arteriovenous fistula in hemodialysis patients

An aneurysmal fistula can continue to provide hemodialysis access for along time, but giant aneurysms should be operated on to prevent complication. The purpose of this study was to describe our experience of the surgical management of giant venous aneurysms that have developed as a complication of dialysis access. Twenty patients with giant venous aneurysms of the AVF underwent surgical procedures at our hospital from December 2003 to December 2010. The diagnoses were made by physical examination and Color Doppler Ultrasonography. There were 12 male and 8 female patients ranging in age from 29 to 68 years with a mean age of 44.6 +/- 12.3 years. Plication of the aneurysmal dilatations was performed in 17 patients. In two patients, aneurysmal dilatations were excised with restoration of the artery. The remaining one patient who received a successful renal transplantation was also associated with brachial artery aneurysm. Venous aneurysmal dilatations were excised and arterial aneurysms were repaired. All patients experienced a marked decrease in the size of venous dilatations. There were no vascular complications during the follow-up period. We suggest that plication is safe and effective in controlling venous dilatation and achieving patency. Reinforcing the suture line using an external mesh may not be required. However, prospective randomized studies will be required to assess the long-term outcomes

Management of combined femoral artery and vein injuries

The aim of this study was to review our experience with combined injuries to the femoral artery and vein, and to analyze the role of venous repair. Thirty two patients with penetrating injuries of the both femoral artery and vein underwent surgical management at our hospital from May 1999 to August 2009. Primary vascular repair was carried out whenever possible; if not possible the interposition graft was used. This study group consisted of 27 males and 5 females, ranging in age from 15 to 72 years with a mean age of 28.3 years. The mechanism of injury included gunshot wounds in 18 patients and stab wounds in 14 patients. Primary arterial repair was performed in 17 patients. Autogenous saphenous vein graft was used in nine patients and vein patch in two patients. Polytetraflouroethylene [PTFE] graft was used in four patients. All patients had associated venous injuries of which 24 patients had primary venous repair, five had vein graft interposition, and two had PTFE graft interposition. Seven patients had fasciotomies. Graft thrombosis occurred in three arterial repairs. Above-knee amputation was required in two patients with femur fracture. Patients with combined femoral artery and vein injuries can be managed successfully with clinical assessment alone. In these dual vascular injuries, both the femoral artery and vein injuries should be repaired to avoid complications. If venous ligation becomes compulsory, adjuvant therapies and techniques should be recommended such as the use of fasciotomy, anticoagulation treatment, elevation of the lower limb and compression stockings

Management of penetrating heart and accompanying lung injuries

Penetrating heart injury is potentially a life threatening condition due to cardiac tamponade or exsanguinating hemorrhage. The aim of this study was to evaluate victims who were referred to our hospital with penetrating heart and accompanying lung injuries and to review our overall outcome with this type of combined injuries. Twenty patients with combined penetrating heart and lung injuries were operated at Yuzuncu Yil University Research Hospital, between May 1999 and January 2010. The diagnosis of combined heart and lung injuries was proved by surgical exploration in all cases. The surgical procedures mainly included the relief of cardiac tamponade, control of bleeding, repair of cardiac and pulmonary lacerations, and coronary artery bypass grafting if required. In this series of 20 patients; there were 18 males and two females between the age of 14 to 60 years, with a mean age of 34.8 +/- 13.5 years. Seventeen victims sustained stab wounds, and the remaining three were injured by a gunshot wounds. In 20 patients there were 22 cardiac chamber injuries. The most commonly injured cardiac chamber was the right ventricle followed by the left ventricle. In addition to the injuries to heart muscle, injuries to the coronary arteries were found in two patients. The most commonly injured lung lobe was the left upper lobe. Our experience shows that early diagnosis and immediate surgical intervention are the main factors affecting patient survival after penetrating heart and lung injuries. Therefore, heart injury should always be kept in mind in victims with penetrating thoracic injuries

Renal cell carcinoma extending into the inferior caval vein: report of two cases

Renal cell carcinoma [RCC] is rare neoplasm and rarely extends to IVC. Perinephric and venous system invasion is an important prognostic sign for RCC. The tumor may grow intraluminally into the renal vein and Inferior Vena Cava [IVC] as an extension of primary tumor. In this report, we present two unusual case of venous system involvement, invasion of RCC into SVC. RCC with tumor thrombus extension into the IVC remains a difficult operative challenge. However surgical intervention should be performed. Our cases were successfully operated and their post operative recovery was uneventful

Management of constrictive pericarditis: a comparative study between median sternotomy and left thoracotomy

Constrictive pericarditis [CP] requires pericardiectomy but the choice of surgical approach remains controversial. Hence we have reviewed our experience of pericardiectomy carried out for CP and compared the results of pericardiectomy performed by median sternotomy versus left thoracotomy with regard to functional outcomes. The study group consisted of 33 patients with CP who underwent pericardiectomy from May 1999 to January 2010 at our institution. There were 22 female and 11 male patients, ranging in age from 5 to 57 years with a mean age of 45 years. Pericardiectomy was performed via median sternotomy in 17 patients [Group A]. In the remaining 16 patients [Group B], pericardiectomy was performed via a left anterolateral thoracotomy in the fifth intercostal space. During the subsequent follow-up, both groups of patients showed a similar and significant improvement in New York Heart Association [NYHA] functional class. In the group A, the mean NYHA functional class decreased from 3.3 +/- 0.7 to 1.8 +/- 0.5 [P = 0.0004]. In group B, the mean functional class decreased from 3.2 +/- 0.9 to 1.6 +/- 0.6 [P = 0.00005]. Also, both groups had a similar and significant improvement in their mean CVP. In the group A, the mean central venous pressure [CVP] decreased from 15.2 +/- 3.1 mmHg to 8.3 +/- 3.2 mmHg [P<0.005]. In the group B, the mean CVP decreased from 15.1 +/- 4.9 mmHg to 7.7 +/- 2.4 mmHg [P<0.004]. Constrictive physiopathology is a problem primarily of the ventricles and can be alleviated by decorticating both the right and left ventricles. Therefore, CP could be relieved through the left thoracotomy or median sternotomy in most cases. However, echocardiographic findings should be considered to prefer thoracotomy or sternotomy approach

comparison between minilaparotomy and conventional approach for the surgical therapy of aortailiac occlusive disease

To search for less traumatizing measures for Aortic Occlusive Disease [AOD] surgeries to improve the recovery from surgery. Another objective was comparison of retroperitoneal minilaparotomy [RML] with conventional transperitoneal classic median laparotomy [TCML] with respect to per-operative and post-operative outcome and complications. It was a retrospective comparative study. All patients undergoing AOD surgery were enrolled. Our comparative data of 20 patients who had AOD surgery by TCML [TCML group] performed from January 2003 to December 2006 and 20 cases of patients who had AOD surgery by RML [RLM group] performed from January 2006 to December 2009 is presented. Chi-square and Fischer test with significance of p value being taken at 0.05 were used for categorical data, while student's t test was used for continuous data. Mean age, gender, the operation and aortic occlusion time was similar between the TCML and RLM groups. The length of stay in the intensive care unit [ICU] and total hospital stay in the RLM group was statistically shorter compared to the TCML group[p<0.05]. Major complications were rare in both the groups. During AOD surgery, RLM appears to be an attractive alternative to traditional TCLM with fewer complications